Linking Science to Policy

This article traces the modern history of alcohol policy research on an international level, focusing on cross-national collaborative studies, a recent phenomenon that has dramatically increased our scientific understanding of how alcohol-related problems can be prevented or reduced through organized action by governments and public health organizations. The studies reviewed here show that during the past 25 years, a small but growing cadre of alcohol research professionals has used a problem-focused, integrative research approach to more closely align alcohol research with public policy.

A lthough governmental authorities have attempted to prevent alcohol problems since antiquity, the scientific study of such problems and the use of alcohol research to inform public policy have been rather recent developments. Not until the rise of modern medicine and the emergence of the world Temperance Movement during the 19th century was alcohol policy 1 recognized as a potential instrument of public health, nor was epidemiological research viewed as a potential instrument of alcohol policy. During the 20th cen tury, numerous attempts were made to employ social science techniques, such as population surveys and trend analyses of mortality data, to evaluate the effects of a wide range of policy options (Babor 1993;Edwards et al. 1994). Such policies included total prohibition, State monopolies, drinking-anddriving laws, school-based alcohol education, alcohol taxation, legislative controls on alcohol availability, age restrictions on alcohol purchasing, and media information campaigns. By the 1970s, social scientists, often under the guidance of the World Health Organization (WHO) or their national governments, began to collaborate across national boundaries to study the effects of alcohol policies on alcohol-related problems.
One major advantage of international scientific collabora tion is the ability of participating scientists to compare and contrast a broad array of policy options across different coun tries. The comparative approach also helps in understanding the cultural idiosyncrasies of drinking and the historical 1 For a definition of this and other terms used in this article, see the glossary, p. 72. determinants of alcohol policies. This article traces the modern history of international policy analysis in the alcohol field by describing a series of innovative and influential crossnational studies that have been published in the past 25 years (see table). These studies, which have been initiated at a relatively constant rate during that time period, have used a variety of approaches-ranging from clinical trials to expert opinions-to arrive at their conclusions. This review pro vides a global perspective on the growing sophistication of alcohol policy research and its relevance to the challenges of the 21st century.

The "Alcohol Control Policies in Public Health Perspective" Monograph
For the purposes of this review, the modern history of international collaboration in the area of alcohol policy research began with the publication of a seminal monograph entitled Alcohol Control Policies in Public Health Perspective (Bruun et al. 1975)-often referred to as the "Purple Book" because of its cover. Sponsored by the WHO's European Office, this international collaborative project brought together alcohol researchers from 13 countries who debated policy issues, evaluated original data, and critically reviewed the world literature on prevention measures. The international work ing group drew its scientific expertise from academic settings and research centers in the Scandinavian countries, the United Kingdom, and North America. The resulting monograph drew attention to the preventable nature of alcohol problems throughout the world and to the role of national governments and international agencies in forming rational and effective alcohol policies.
The Purple Book stimulated heated debates on alcohol problems and their prevention, not just among academics but also among policymakers and medical practitioners. The most controversial aspect of the book was its main thesisthat the average amount of alcohol consumption in a society directly affects the prevalence of problems experienced by that society. A corollary to this thesis is that one of the most effective ways to prevent alcohol problems is through policies directed at reducing average alcohol consumption, particularly by placing limits on the physical and economic availability of alcohol through such methods as restricted hours of sale and alcohol taxes. Although not inconsistent with the contemporary "harm reduction" approach, which focused atten tion on groups at high risk for alcohol problems (e.g., drink ing drivers and chronic alcoholics) the prevention methods promoted in the Purple Book drew attention to the full spec trum of drinkers in a society, not just alcoholics. As noted by Asvall (quoted from Edwards et al. 1994): "Few books have had so much influence on the thinking and actual policymaking in this area. Its great impact was due to the authority of the group, to the very thorough way in which they did their work, and to the practical form in which they packaged their conclusions" (p. vi).

International Study of Alcohol Control Experiences
The International Study of Alcohol Control Experiences (ISACE) project was initiated by the WHO and collaborating research institutes to continue the work first summarized in the Purple Book, which had characterized alcohol control policy as a sequential process from policy implementation to reduced drinking to fewer alcohol-related problems. According to historical observations, alcohol consumption trends between World War II and the early 1970s were surprisingly similar in Europe and North America, with the same increases occurring in countries with different economic conditions and alcohol control policies. The aim of the ISACE project was to study the dynamics of the post-World War II increase in alcohol consumption to better understand how alcohol control policies affect alcohol consumption and its adverse consequences (Mäkelä et al. 1981;Single et al. 1981;Giesbrecht et al. 1983). The project was carried out as a series of case studies in seven countries: Finland, the Netherlands, Poland, Switzerland, Ireland, Canada, and the United States. The 18 project investigators functioned as a scientifically autonomous body but benefited from the support of and col laboration with the WHO's European Office.
Despite the diversity in drinking patterns and alcoholrelated problems across the seven countries, the study supported the main thesis of the Purple Book-namely, that the post-war changes in the overall consumption of alcoholic beverages had a direct bearing on the increased prevalence of alcohol-related problems. Specifically, six conclusions emerged from the study: Preventive considerations carry little weight in the formation of economic policies governing the availability of alcohol.
With increasing acceptance of drinking in the everyday life of Western societies, public policies tend toward con trol of excessive drinking in the individual (e.g., through treatment or punishment) rather than toward populationbased approaches.
Because alcohol availability and control involve complex cultural, social, and political phenomena, policy changes should be made with caution and with a sense of experi mentation to determine their effectiveness.
Event-based drinking problems, such as alcohol-related traffic crashes and violence, will continue to occur frequently in industrialized societies, requiring risk-reduction measures directed at both the drinking environment and the exces sive drinker.
The health and social costs associated with alcohol should be taken into account in the development of international trade agreements.
Governments should carefully reconsider the policy of granting fiscal incentives to support the promotion and distribution of alcoholic beverages.  (Ritson 1985;Rootman and Moser 1984). Combining social survey research with com munity organization techniques, the WHO Community Response Study focused on formal and informal responses to alcohol-related problems in both rural and urban communi ties in Mexico, Zambia, and Scotland. In the first phase of the project, both the general population and the staff and clientele of a wide variety of health and social agencies were surveyed with respect to alcohol use, alcohol-related prob lems, and community responses, revealing both similarities and differences among these diverse countries. For example, in all three countries, men drank more than women, and the police devoted a major part of their time to managing people with alcohol-related problems. However, rates of abstention were much higher in Mexico and Zambia than in Scotland. Drinking by adolescents was tolerated more in Scotland, whereas alcohol-related problems were more apparent in Mexico and Zambia. In Scotland, specialized services (e.g., alcoholism treatment programs and counseling) played a major role in managing alcohol-related problems, whereas few such services existed in Mexico and Zambia, and other sources of help (e.g., family members and native healers) were more likely to be mentioned in those countries.
In the second phase of this project, community interven tion projects were conducted in the three first-phase sites (Room 1990). For example, in Edinburgh, Scotland, the project contributed to the planning of prevention activities by an ongoing council of community agencies. In Mexico, the project gave impetus to the formation of an Al-Anon group for wives of heavy drinkers. And at the international level, the project developed a practical manual for commu nity planning and action for use by the WHO member States (Rootman and Moser 1984).
At best, the attempt to translate local research on alcoholrelated problems into community action proved to be more difficult than anticipated, especially in relation to the devel opment of meaningful community responses. Nevertheless, the Community Response Study showed how coordinated international research activities could be conducted within the boundaries of limited available national resources, and how this research data could be relevant to local, national, and international alcohol policies (Rootman and Moser 1984). The study generated some of the first comparative data col lected through identical population surveys in different coun tries. It also suggested that coherent responses to alcohol-related problems require adequate epidemiological data; joint planning by a wide variety of community leaders; and communitybased, culturally specific responses. Overall, the Community Response Study can be seen as the forerunner of a whole tradition of international comparative research meetings on evaluated community action projects in the alcohol field (Giesbrecht et al. 1990), suggesting that the value of this project goes far beyond its initial scope.

State Monopolies and Alcohol Prevention
Initiated in 1986, this project focused on the potential con tributions of State monopoly systems to the control of alcoholrelated problems (Kortteinen 1989). The purposes of State monopolies include curbing private profit, providing tax rev enues to the State, protecting domestic industries, promot ing exports, safeguarding the quality of alcoholic beverages, and reducing the prevalence of alcohol-related problems. The project, which included seven developed countries and eight developing countries, was a joint venture between the WHO and two Finnish organizations, the Social Research Institute of Alcohol Studies and the Finnish Foundation for Alcohol Studies.
The investigators found that State monopolies vary con siderably in form and scope, covering both the production and the distribution of alcoholic beverages, in the following ways: First, in some countries, the monopolies apply only to certain alcoholic beverages; in other countries, they apply to all such beverages. Second, regarding the effectiveness of monopoly systems, the data suggest that the more strongly a State intervenes (i.e., the more extensive a State monopoly is), the lower the per capita consumption of alcohol will be. Third, although most monopolies were established with pub lic health objectives in mind, their success as a specific form of alcohol control differs from one country to another and presupposes public support. Control measures that do not enjoy public support may produce undesirable effects, such as the generation of a black market. Fourth, stable political conditions and the structure of a country's political system are important. Fifth, in many countries, religion plays a role. For example, Catholicism has been implicated in the heavy drinking patterns of the wine-producing countries of Southern Europe, whereas Islam has had an influential role in restrict ing alcohol use in the Muslim countries (Edwards et al. 1994). And sixth, developing countries can never "copy" a developed society's alcohol-control system. Alcohol policies have to be tailored to suit the history and culture of each particular country.

International Studies in the Development of Alcohol Treatment Systems
In 1984, an international conference held in Sweden discussed societal responses to alcohol problems, including the devel opment of treatment systems. The conference identified intriguing differences in the ways various countries managed alcohol problems, and led to the formation of an international collaborative group of social scientists devoted to the exploration of the comparative and structural aspects of alcoholism treat ment systems. The main product of this project was a book entitled Cure, Care, or Control: Alcoholism Treatment in Sixteen Countries (Klingemann et al. 1992). The 32 collabo rating investigators reviewed the "cure" of alcoholism in health care systems, the "care" of problem drinkers in social welfare agencies, and the "control" of problem drinkers in the crimi nal justice system.
The study found that after World War II, the societal view of alcoholism treatment had shifted from a "moral" concept to an "illness" concept, with many countries also mixing these concepts into a newer "alcohol problems" approach. In most countries, the general boost in treatment resources was asso ciated with increasing deinstitutionalization (i.e., from inpa tient to outpatient settings), decentralization to communitybased services, and differentiation into a greater variety of services. For example, outpatient treatment became relatively more important than inpatient treatment in almost all coun tries. In addition, the demographic profile of service recipi ents shifted from an overrepresentation of the lower social strata to growing numbers of middle-class clients.
A major finding was the wide disparity in treatment services, even among developed countries. Remarkably, the wineproducing countries, which have the highest per capita alcohol consumption, were found to have smaller treatment systems (e.g., fewer resources or treatment programs). Spirits-drinking countries with relatively lower per capita consumption invested the most in alcoholism treatment services. Overall, no sim ple relationship existed between the density of treatment ser vices and the amount of alcohol problems in a given country.

The Primary Care Project
During the 1980s, several interrelated projects were initiated by the WHO to provide a scientific basis for a public health approach to alcohol screening and brief intervention in pri mary care settings. Recognizing the importance of primary care to the delivery of health services in much of the world and the relative absence of specialized services for treating alcohol dependence, the WHO commissioned a study (Saunders et al. 1993) to develop an international screening test that could be used in different countries. The project was inspired by the notion that once a standardized screening test was developed for use in primary care settings, it would stimulate early intervention, thereby reducing the burden of alcohol problems in different societies, including those without a specialized treatment system.
Working with alcohol researchers in Norway, Bulgaria, the United Kingdom, Mexico, Australia, and the United States, the WHO sponsored a validation study of different screening procedures that led to the development of the Alcohol Use Disorders Identification Test (AUDIT) (Saunders et al. 1993). Unlike previous screening tests, which were designed primar ily to identify alcoholics, the AUDIT was designed to detect hazardous and harmful drinkers as well as people with alcohol dependence. Since its publication in 1989, the 10-question AUDIT has generated a large body of methodological and epidemiological research (Allen et al. 1997) and has become one of the most widely used alcohol screening tests in the world.
In a second phase of this project, a multicenter clinical trial of brief intervention procedures was carried out in pri mary health care settings in Costa Rica, Australia, the United Kingdom, Norway, Mexico, Kenya, Bulgaria, and the former Soviet Union (WHO Brief Intervention Study Group 1996). The study showed that brief interventions could significantly affect both consumption and intensity of drinking, with 5 minutes of simple advice working as effectively as 20 minutes of counseling. The findings suggested that in a population of heavy drinkers, behavior change is more a function of moti vational factors and social influence than of the moderation skills and social learning techniques typically used in behav ioral self-control training. The overall decline in alcohol con sumption following the intervention was not attributable solely to the patients who achieved an abstinence goal or who gave up daily drinking. Rather, changes appeared to be distributed across a broad spectrum of the drinkers who reduced their consumption by small but clinically meaningful amounts.
Building on these WHO initiatives in instrument devel opment and applied research in primary care, efforts are now being made to evaluate dissemination strategies at the com munity and national level in a large number of countries (Heather 1998). This phase of the project developed procedures to overcome barriers to screening and brief intervention at the level of the individual physician, allied health personnel, and the health care system itself. Such barriers include lack of time, training, and knowledge. Through the involvement of collaborating investigators from more than 20 countries over the course of two decades, the Primary Care Project has demonstrated how clinical research can directly influence the early identification of alcohol problems in organized systems of medical care.

The Alcohol and Public Policy Project
Two decades after the publication of the Purple Book, a sim ilar project was commissioned by the WHO to update the world literature pertaining to alcohol policy. The new study produced Alcohol Policy and the Public Good, a book that proved to be as controversial and thought-provoking as its predecessor (Edwards et al. 1994). Published in 1994 and subsequently translated into 8 languages, it was prepared by an independent group of 14 scientists from 9 countries who worked together in collegiate fashion over an intensive 3year period. The project was conducted in close collabora tion with the WHO's European Office to bring public health researchers into the realm of policy analysis through litera ture reviews, conference presentations, original research, and consultations to national governments. The book was derived from the preparation of background papers (Holder and Edwards 1995), group discussions, and the interim work of a small editorial team, all of which led to the authors' con sensus regarding the scientific basis of alcohol policy on an international level.
The book concluded that public health policies on alcohol have come of age because of strong evidential underpinnings derived from the scientific research that has grown in breadth and sophistication since 1975. After reviewing the evidence on alcohol taxation, environmental control measures, drunkdriving countermeasures, school-based education, community action programs, and treatment interventions, the project participants arrived at two major conclusions: • The research establishes that public health measures of proven effectiveness are available to curb the widespread costs, health consequences, and social problems related to alcohol use.
• It is appropriate to employ two intrinsically complementary approaches: a) responses that influence per capita alcohol consumption and aggregate-level problems, and b) policies targeted at specific drinking contexts and behaviors.
Alcohol Policy and the Public Good not only established a scientific basis for regional policymaking, such as the European Alcohol Action Plan (World Health Organization 2000) but also provided an objective analysis on which to build globally relevant policies.
In the short period since this book was published, new developments have occurred in the epidemiology of alcohol problems, particularly in the emerging states of the former Soviet Union and in countries of the developing world. With the growth of the knowledge base and the maturation of alcohol research, a new phase of the project, starting in 1998, has continued to evaluate the epidemiology of alcoholrelated problems and the influence of evidence-based alcohol policies on public health (Babor 2000). In a new epidemio logical analysis conducted for the second phase of the Alcohol and Public Policy Project, Rossow (2000) evaluated crossnational data on the social costs of alcohol, showing that both heavy drinking over time and acute intoxication on spe cific drinking occasions increase the risk of suicidal and vio lent behavior. In another study, Brady (2000) reviewed the lit erature on indigenous minorities living in four developed countries (United States, Canada, Australia, and New Zealand) where socioeconomic isolation has been associated with a distinct drinking pattern (i.e., binge drinking on typical occasions with virtually no moderate drinking). The analysis concluded that national alcohol policies have had a limited impact on the alcohol-related problems of indigenous people. As a consequence, native peoples have now begun to develop their own ways to control the local supply and distribution of alcohol. Finally, Graham (2000) evaluated the evidence on the effectiveness of alcohol policies designed to prevent problems within relatively circumscribed drinking environ ments, such as bars. Despite some promising findings to suggest that on-premise intervention programs, such as train ing in responsible beverage service, can be effective, the study concluded that program design, outcome evaluation, and theory development needed to be greatly improved before such environmental approaches to prevention could be pro moted with confidence.
What these papers have in common with the Alcohol and Public Policy Project is their ability to critically evaluate sci entific evidence and provide practical guidance on policies related to the prevention of alcohol problems in different societies.

Drinking Patterns and Problems in Developing Societies
The analyses and arguments described in Alcohol Policy and the Public Good were based almost entirely on material from developed societies. Because the WHO has responsibility for public health on a global basis, it also commissioned a simi lar study drawing on material from developing societies. An independent group of 12 scholars began a systematic effort in 1998 to review the available literature, compile relevant databases, and develop case histories for selected countries (Riley and Marshall 1999). The volume resulting from this study (Room et al. in press) is called Alcohol in a Changing World: Drinking Patterns and Problems in Developing Societies.
The starting point for the report was the epidemiological finding that the consumption of alcoholic beverages is respon sible for a substantial proportion of health and social prob lems in developing societies. The highest burden is in Latin America, where alcohol is estimated to account for almost 10 percent of all cases of disability and death. Although the burden is less in other developing regions, alcohol nonetheless accounts for a considerable amount of premature death and disability. Total alcohol consumption may be relatively low in develop ing countries, but a pattern of occasional heavy drinking can be associated with detrimental consequences, such as alcoholrelated injuries from traffic crashes or violent behavior.
The findings of the report also suggest that with economic development and rising incomes, alcohol consumption and resulting problems are likely to increase, presenting develop ing nations with new challenges to adopt effective alcohol policies. Another factor likely to have an adverse influence is global trade agreements. With the growing emphasis on free trade and free markets, international institutions have pushed to dismantle existing control measures, such as State alcohol monopolies and taxes on alcohol.
Despite these trends, the report also showed that strategies are available to governments for limiting the harm from drink ing. These strategies include the following: • Persuading people not to drink or educating them about ways to limit harm • Prescribing penalties for irresponsible drinking behavior • Providing alternatives to drinking or to drink-connected activities • Treating or otherwise helping people who experience prob lems with drinking

INTERNATIONAL PERSPECTIVES
• Reducing the alcohol user's risk of harm in other areas (e.g., by requiring motorcycle helmets) • Regulating the availability of alcohol or the conditions of its use • Working with social and religious movements oriented to reducing alcohol problems.

The European Comparative Alcohol Study
The European Comparative Alcohol Study (ECAS) was a col laborative analysis of alcohol consumption and alcohol poli cies in 15 European countries. The main purpose of the pro ject was to understand the dynamics of population changes in alcohol consumption and drinking patterns as well as the influence of different policy measures on these changes. The ECAS project was funded by grants from the European Union and several of its member countries. Drawing on both comparative and longitudinal data collected between 1950 and 1995, two substantive issues emerged from this project. The first issue is the "homogenization" of alcohol consumption patterns within Europe, especially in relation to economic develop ment, living conditions, and public policies. The second issue concerns the "natural" time scale of changes in alcohol con sumption, which may offer a more realistic perspective on alco hol policy measures.
The term "homogenization" refers to the diminishing dif ferences among nations in per capita consumption levels and drinking patterns (Leifman 2000). Between 1950 and the mid-1970s, a homogenization of beverage preferences was observed in the Mediterranean wine-drinking countries, the Central European beer-drinking countries, and the spiritsdrinking countries of Northern Europe. In each group of countries, the dominating beverage lost some of its popular ity. Since the mid-1970s, the process of homogenization has slowed down, although it has been sustained by a continuing reduction of wine drinking in the Mediterranean countries. Homogenization of per capita alcohol consumption has followed a similar two-step process, with the most dramatic changes taking place between 1950 and 1975. Despite homogeniza tion, however, significant differences between the countries remain, and many qualitative features of drinking patterns seem to be persistent and immune to change, such as the pattern of weekend binge-drinking in the Scandinavian countries (Simpura and Karlsson 2000).
The ECAS has also produced a time series analysis of alcohol consumption between 1950 and 1995 in relation to various forms of mortality in 14 countries (Norström 2001). These analyses show that an additional liter of per capita alcohol consumption has a more adverse effect in the bingedrinking countries of Northern Europe than in the steadier drinking countries of Southern Europe, suggesting the importance of drinking patterns in any consideration of alcohol policies.
According to Simpura (2000), the ECAS findings show that alcohol-related phenomena generally change slowly. Changes in alcohol consumption in the European countries take place over generations, rather than over a decade or sev eral years. Furthermore, alcohol consumption is affected not only by alcohol policies but also by a broad array of economic and social forces. This time frame makes it difficult to imple ment policy interventions that will have an immediate effect on drinking patterns or alcohol-related problems. Finally, the ECAS analysis of alcohol-related harm indicates that the link between per capita alcohol consumption and alcohol-related harm is not disappearing, although it is much more nuanced and complicated than suggested in earlier interpretations of this relationship.

The Supply-Side Initiative
From a public health perspective, it is important to understand the role of alcohol supply at the local, national, and interna tional levels and its contribution to drinking and alcohol problems. The Supply-Side Initiative (SSI) was devoted to the study of the relationship between the supply of alcohol, the amount of alcohol consumed, and their joint connection with the prevalence of alcohol-related problems. The project was particularly interested in the analysis of cross-national investments to build alcohol production facilities in develop ing countries in Africa and South America. The project also focused on the rapid increase in alcohol supply in the Baltic countries and Russia and on the impact of international trade agreements on the regulation of alcohol importation within countries. The SSI was conducted by a group of indepen dent researchers from the United States, Norway, Finland, and Sweden.
During the first phase of the project, a series of articles was commissioned to provide a comprehensive review of the scientific knowledge about the alcohol supply system. The articles describe the production, distribution, marketing, and international trade of alcohol and the relationships of these factors to alcohol consumption. For example, Jernigan (2000) reviewed global commodity chains and analyzed the dynam ics of power and profit making in globalized production networks. These networks, which are made up of multiple firms and occur in many national settings, account for a substan tial portion of the alcohol supply in developing countries. Particularly in the brewing and distilling industries, a small number of transnational firms now control networks of local producers, importers, advertisers, and distributors. The networks have proceeded to embed transnational brands in the local culture, using product design and marketing techniques to influence local drinking practices. Thus, standard European and American bottled beers are now promoted in developing countries as the beverage of choice for discriminating drinkers rather than the traditional, low-alcohol-content beers that are brewed locally. The review concluded that globalization and rapid social changes, especially the standardization of products across national borders, have had a major influence on the alcohol supply in developing countries.
Similarly, Grieshaber-Otto and colleagues (2000) investi gated the influence of international trade agreements on alcohol consumption and alcohol problems. The article con cluded that a fundamental incompatibility exists between gov ernment efforts to minimize the harm associated with alcohol, particularly by regulating its supply, and international com mercial treaties that promote the free flow of goods, services, and investments. The analysis also suggests that the North American Free Trade Agreement (NAFTA) and the World Trade Organization agreements present new challenges to local and national alcohol control measures. The implications of these agreements for public health have rarely been consid ered. The alcohol prevention measures considered the most effective (Edwards et al. 1994)-restricting the number and locations of retail outlets, taxing alcohol, and regulating bev erages according to alcohol strength-are the ones most likely to be neutralized by these trade agreements. Edwards and Holder (2000) assessed the overall relevance of supply-side issues. According to their analysis, supply-side issues are relevant to public health at every level, from the influence of drinking outlets on local communities to the impact of globalization on worldwide drinking levels. Most likely, general principles of supply side economics also drive the alcohol supply. For example, the pressure for increased profits and market share often constitutes the major influ ence on decisionmaking. Because of alcohol's effects on traf fic crashes, chronic illness, social and family problems, pub lic disorder, and crime, public health researchers are begin ning to look at alcohol as one of many harmful substances, rather than considering alcohol to be "just another commod ity" (Edwards and Holder 2000).

Evolving Views of Alcohol Policy
Public policies are authoritative decisions made by governments through laws, rules, and regulations (see Longest 1998). The word "authoritative" indicates that the decisions come from the legitimate purview of legislators, judges, and other public officials and not from private industry, public interest groups, nongovernmental organizations, or other entities. Generally, alcohol policies are directed at populations (e.g., underage drinkers or pregnant women) and organizations (e.g., health systems) particularly affected by alcohol as well as at individ ual drinkers.
From the perspective of this review, the central purpose of alcohol policy is to enhance health by reducing the harm caused by alcohol. The pursuit of health is one of modern society's most highly cherished values, which may account for the growing interest in alcohol policy research. However, public

G L O S S A R Y
Alcohol control: Any government measure that relates to the purchase, production, or trade in alcoholic beverages, regardless of the aims of such measures. Alcohol-related problems: Any of the range of adverse accom paniments of drinking alcohol, including medical, social, and psychological consequences. It is important to note that "related" does not necessarily imply causality. Alcohol policy: Measures designed to control the supply of and/or affect the demand for alcoholic beverages in a popu lation (usually national), including education and treatment programs, alcohol control, and harm-reduction strategies. Implying the need for a coordination of governmental efforts from a public health and/or public order perspective, the term originated in the Scandinavian countries and has spread widely since the 1960s. Alcohol supply: The production, distribution, import, export, and retail sale of alcoholic beverages. Alcohol treatment system: A set of organizations, agencies, programs, and referral channels that offers people treatment or help for alcoholism, alcohol dependence, or alcohol-related problems.  Babor et al. 1996). These organizations tend to favor prevention efforts that are oriented toward information and education, the least effective evidence-based policies (Giesbrecht 2000). Until the 1970s, the scientific evidence for the prevention and treatment of alcohol problems was inadequate to serve as a basis for alcohol policymaking. The studies reviewed in this article, however, indicate that progress has been made in the past 25 years both in practical knowledge and in the process of scientific discovery. Using what some analysts have called a problem-focused integrative research approach, the projects presented here typically include a programmatic sequence of empirical studies and literature reviews organized around a common theme. Because they last between 5 and 15 years, they do not fit neatly into the traditional category of an investigator-initiated clinical study. Rather, these projects rely heavily on population-based public health sciences, such as epidemiology and health economics, with the main impetus coming from interdisciplinary, cross-national collaboration among social and behavioral scientists. A final ingredient of these projects is their independence, autonomy, and scrupu lous avoidance of even the appearance of conflict of interest.
Although it is difficult to generalize from such a diverse group of studies, they have identified several important themes: • Alcohol policies that affect drinking patterns by limiting access, discouraging driving under the influence, and reducing the legal purchasing age are likely to reduce the harm linked to specific drinking patterns.
• Health policies have a major impact on alcoholism treatment and clinical preventive services available to people within a country or region through health care financing and the organization of the health care system itself. No clear rela tionship exists, however, between the type and density of ser vices and the prevalence of alcohol-related problems.
• Individual approaches to prevention (e.g., school-based prevention programs) have a much smaller effect on drinking patterns and problems than do populationbased approaches that affect the drinking environment and the availability of alcohol (Edwards et al. 1994).
• Alcohol policy is rarely dictated by scientific evidence, despite major advances in the understanding of drinking patterns, alcohol-related problems, and policy interven tions. Some notable exceptions to this statement include research-based policies related to minimum purchasing age and blood alcohol levels for impaired drivers.
• There seems to be a fundamental incompatibility between the economic and political values of free trade, unfettered marketing, and open access to alcohol, on the one hand, and the public health values of demand reduction, harm reduction, and primary prevention, on the other hand.
Alcohol policies are often based on a combination of political expediency, commercial interests, common sense, and public safety. Of all the factors that could influence alco hol policy, scientific research is perhaps the most important, but least influential, route to minimizing or preventing alcoholrelated problems. Nevertheless, the projects summarized in this article demonstrate the value and potential of interna tional collaborative research that is oriented toward mean ingful policy issues.